Sir,
A 50-year-old female recently diagnosed with bronchial asthma presented with acute dyspnoea and wheeze. She did not respond to conventional treatment and progressed to acute respiratory failure requiring ventilation. The initial chest radiograph [Figure 1] was unremarkable. Two days later the patient developed left lung atelectasis [Figure 2], fiber optic bronchoscopy revealed a foreign body [Video 1], a betel nut in the left main bronchus. The betel nut [Figure 3] was removed and the patient was extubated five days later. The patient was a betel nut chewer and had aspirated it. Wheeze would have been heard due to a check-valve mechanism of airflow past the foreign body, and eventually a stop-valve mechanism, resulted in atelectasis [Figure 4].
Figure 1.
Chest radiograph on day 1 immediately after intubation unremarkable
Figure 2.
Chest radiograph on day 3, patient on ventilator, showing left ling atelectasis
Figure 3.
Emergency bronchoscopy revealed a foreign body in left main bronchus
Figure 4.
Pathogenesis of wheeze heard would have been due to a bypass/check-valve mechanism of airflow past the foreign body initially, and eventually a stop-valve mechanism, resulting in atelectasis
Airflow through a narrow airway generates a coarse whistling sound, which is known as wheeze and is often equated with asthma. Chevalier Jackson recognized “all that wheezes is not asthma” and described the above mentioned mechanism of bronchial obstruction by a foreign body.[1,2] Another cause of wheeze that is at time misdiagnosed as asthma is pulmonary edema. Described as “cardiac asthma”, wheeze is heard due to bronchial wall and intraluminal edema fluid cause narrowing of the small airways.[3] Other processes that narrow the diameter of an airway inducing wheezing include chronic obstructive pulmonary disease, endobronchial or endotracheal stenosis, buildup of airway secretions, endobronchial obstruction, upper airway obstruction, and allergic reactions.[4]
Establishing that wheezing is not due to asthma requires attention to the patient's history, physical examination results, and response to therapy.
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REFERENCES
- 1.Braman SS, Davis SM. Wheezing in the elderly: Asthma and other causes. Geriatr Clin North Am. 1986;2:269–83. [PubMed] [Google Scholar]
- 2.Ahmed T, Krieger BP, Wanner A. Differential diagnosis of asthma in the elderly. In: Barbee RA, Bloom JW, editors. Asthma in the elderly. New York: Marcel Dekker; 1997. pp. 93–120. [Google Scholar]
- 3.Osler W. Lectures on angina pectoris and allied states. New York: Appleton; 1897. p. 81. [Google Scholar]
- 4.Krieger BP. When wheezing may not mean asthma. Postgrad Med. 2002;112:101–11. doi: 10.3810/pgm.2002.08.1282. [DOI] [PubMed] [Google Scholar]
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